J Cerebrovasc Endovasc Neurosurg.  2021 Jun;23(2):152-158. 10.7461/jcen.2021.E2020.12.002.

Middle meningeal artery embolization for postoperative supratentorial chronic subdural hematoma occurring after posterior fossa neurosurgery

• Park H
• Park HJ
• Kang HS
• Lee EJ

• KMID: 2517029
• DOI: http://doi.org/10.7461/jcen.2021.E2020.12.002

Abstract

Chronic subdural hematoma (CSDH) after posterior fossa surgery is rare but may occur. A 70-year-old man with trigeminal neuralgia underwent microvascular decompression. The patient took several medications for trigeminal neuralgia and tremor for a long time. The patient tended to bleed easily and did not stop well, but the bleeding was thoroughly controlled intraoperatively. A month later, he presented with left side weakness, and brain computed tomography showed huge amount of CSDH in the right cerebral convex with midline shifting. Although CSDH was completely drained via burr hole trephination, the brain was not fully expanded, and the CSDH recurred a month later. CSDH was evacuated, but there was still considerable subdural space and remained small CSDH in another superficial subdural space. We considered that the patient was at high risk of recurrence of CSDH and performed middle meningeal artery (MMA) embolization. Afterward, he did not suffer a recurrence. Here, we reviewed the risk factors of CSDH recurrence and the usefulness of MMA embolization in the treatment of CSDH, and we recommend upfront MMA embolization as an effective adjuvant to treat CSDH in patients at a high risk of recurrence of CSDH.

Keyword

Chronic subdural hematoma, Risk factor, Recurrence, Embolization, Middle meningeal artery

Figure

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  Fig. 1. (A) On immediate postoperative brain CT, there were not unusual postoperative findings except mild pneumocephalus. (B) The 4th days after surgery follow up brain CT showed an extra-axial fluid collection with CSF density with 7 mm thickness along the right cerebral convexity. CT, computed tomography; CSF, cerebrospinal fluid.

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  Fig. 2. (A) On a month after surgery, brain CT showed chronic subdural hematoma at right convexity. The patient complains of symptoms like left-side extremities weakness. (B) On immediate postoperative brain CT after burr hole trephination, the hematoma was washed out. (C) Brain was not fully re-expanded on 2nd day after the surgery brain CT and an excessive subdural space filled with CSF. CT, computed tomography; CSF, cerebrospinal fluid.

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  Fig. 3. (A) A month later, from hematoma removal, follow up brain CT showed a recurrence of chronic subdural hematoma without any symptoms. (B) Immediate second postoperative brain CT showed a small amount of acute staged hematoma remained in the subdural space. (C) MMA embolization was performed for diminishing a recurrence rate of chronic subdural hematoma. (D) A month later, brain CT from the second burr hole trephination and MMA embolization showed still excessive subdural space filled with subacute staged hemorrhage. (E) Three months later, from the second operation and MMA embolization, brain CT showed complete resolution of chronic subdural hematoma. CT, computed tomography; MMA, middle meningeal artery.

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